Commissioning: further issues - Health Committee Contents

Written evidence from the Royal College of General Practitioners (CFI 30)

1.  The Royal College of General Practitioners is the largest membership organisation in the United Kingdom solely for GPs. Founded in 1952, it has over 42,000 members who are committed to improving patient care, developing their own skills and promoting general practice as a discipline. We are an independent professional body with enormous expertise in patient-centred generalist clinical care. Through our General Practice Foundation, established by the RCGP in 2009, we maintain close links with other professionals working in General Practice, such as practice managers, nurses and physician assistants.

2.  The College welcomes the opportunity to respond to this inquiry, which has been drawn up with reference to the College's core statement of object, vision, purpose and values:


The Royal College of General Practitioners is a registered charity with the Object:

To encourage, foster and maintain the highest possible standards in general medical practice and for that purpose to take or join with others in taking any steps consistent with the charitable nature of that object which may assist towards the same.


A world where excellent person centred care in general practice is at the heart of healthcare.

Our role is to be the voice for General Practice in order to: promote the unique patient - doctor relationship; shape the public's health agenda; set standards; promote quality and advance the role of general practice globally.


To improve the quality of healthcare by ensuring the highest standards for general practice, the promotion of the best health outcomes for patients and the public and by promoting GPs as the heart and the hub of health services.

We will do this by:

—  ensuring the development of high quality general practitioners in partnership with patients and carers;

—  advancing and promoting the academic discipline and science of general practice;

—  promoting the unique doctor-patient relationship;

—  shaping the public health agenda and addressing health inequalities; and

—  being the voice of General Practice.


The RCGP is the heart and voice of General Practice and as such:

—  We protect the principle of holistic generalist care which is integrated around the needs of and partnership with patients.

—  We are committed to equitable access to, and delivery of, high quality and effective primary healthcare for all.

—  We are committed to the theoretical and practical development of general practice.


3.  We believe that good commissioning is about being a good GP. It is about understanding the impact of clinical decisions on the public's health and purse, understanding the need to practice safely, effectively and in an evidence based manner and about understanding how the needs of patients can be best served through the design of services that meet their needs.

4.  In addition, we believe that good commissioning is about engaging in clinical dialogues with colleagues in health and social care, and establishing effective channels of communication between patients, the public and elected representatives. The RCGP has already advocated the potential advantages of cross-practice working in its work on federated practice.[67]

5.  However, as indicated in a snapshot survey carried out by the RCGP in January 2011, more than half of GPs who responded are concerned that the proposed health reforms will not lead to improvements in care for patients. Over 50% disagreed that the proposed model of GP commissioning would create a patient-led NHS. The poll attracted more than 1,800 responses.


The Committee believes it is essential for clinical engagement in commissioning to draw from as wide a pool of practitioners as is possible in order to ensure that it delivers maximum benefits to patients. GPs have an essential role to play as the catalyst of this process, and under the terms of the Government's changes they, through the commissioning consortia, will have the statutory responsibility for commissioning. They should, however, be seen as generalists who draw on specialist knowledge when required, not as the ultimate arbiters of all commissioning decisions. The Committee therefore intends to review the arrangements proposed for integrating the full range of clinical expertise into the commissioning process. (Paragraph 96)

6.  The RCGP are concerned about the potential split in the NHS reforms between GPs as commissioners and others as providers. We recognise the need to work with our specialist colleagues, other members of the healthcare team, patient groups, social care professionals and managers to provide safe, effective and evidence based solutions to meet patients' healthcare needs. The College also agrees engagement with the wider clinical community is essential, but accepts that GPs as commissioners will have to take a lead role.

7.  We think that consortia can have a role in facilitating better communication between primary and secondary care, and developing more stable care pathways, so that standards of referral may be improved.

8.  The College is already working to improve integrated working between general practice and the mental health sector. We strongly support the recently established Joint Commissioning Panel for Mental Health (JCP-MH). This is an initiative between the Royal College of Psychiatrists, the Royal College of General Practitioners, the Association of Directors of Adult Social Services, the NHS Confederation, Rethink, Mind and the National Survivor and User Network. It will publish a practical framework for mental health commissioning in April 2011 aimed specifically at those commissioning during the current transition from PCT to GP Consortia.

9.  Time for the development of appropriate skills, abilities and experience are essential if GPs are to play these lead roles and deliver high quality services in a changing healthcare system. To do this, GPs will require the right support and resources to assist their professional development. The RCGP will provide guidance, education and training opportunities, and ensure the sharing of good practice to assist our members to develop the necessary skills to lead effective clinical primary care within the context of GP consortia and commissioning groups if these pass into law.

10.  To demonstrate our support for clinician-led commissioning, RCGP has developed the RCGP Centre for Commissioning with its funding partner - the NHS Institute for Innovation and Improvement to equip GPs, practices and GP consortia with the skills, competencies and expertise required to deliver effective healthcare commissioning which ensures patient-focused, safe, high quality healthcare and improved local health outcomes.

11.  Our principles for effective commissioning, laid out in the new RCGP Commissioning Competency Framework, provide an excellent platform for clinicians and managers across all sectors to build an even better NHS. The Commissioning Competency Framework is supported by a new programme of education, training and organisational development support.

12.  It is important to bring on the next generation of GP clinical leaders. Enhanced opportunities in the early years of GP training would allow GPs to gain a better understanding of commissioning, prepare for advocacy, service development and leadership roles in their local community.

Although the Committee understands the value of the separation of the commissioner and provider functions it believes it is important that this function separation is not allowed to obstruct the development of high quality and cost effective service solutions. We therefore intend to review the arrangements proposed in the Bill for reconciling these conflicts. (Paragraph 102)

13.  The RCGP recognises the risk of conflicts of interest if GPs are to be both commissioners and providers. However, we believe GPs can manage the provider and the commissioner roles as long as there is strong governance. Many GPs have a special interest which can make a major contribution to care pathways and efficient use of resources. All GPs who are providers will also be part of commissioning consortia and it would also be a serious loss of expertise if we cannot use GPs to provide services that the NHS Commissioning Board would wish to commission. The situation can be resolved through excellent governance systems and transparency. Lay representation will be important to assist identification of any serious conflict of interests and maintain transparency.

14.  Innovation is critical to deliver better services for patients and deliver the cost savings the NHS requires. To deliver this innovation GPs should not be constrained from developing new provider offers which can be commissioned from their consortia if that is the best way of ensuring high quality services for patients

15.  One of the principles underpinning our values for effective commissioning is the importance of a trusting and collaborative relationship between commissioners and providers. That is part of what it means to put patients at the heart of the system - deliberately removing artificial boundaries and obstacles to a cohesive and cooperative NHS.

16.  Local specialist colleagues might be very valuable in service redesign, but they should not be excluded from a tender under the "any willing provider" rule. Nor should GPs who offer a referral service within their own area be excluded as they may provide a cost effective local service. Creative solutions require a collaborative process, and that's how we can deliver better services and outcomes for our patients.

The Committee agrees that local engagement with the commissioning of primary care services is important and therefore welcomes this development. The potential conflict of interest between consortia and local primary care providers does however remain. We therefore intend to review the arrangements proposed in the bill for the commissioning of primary care services. (Paragraph 104)

17.  As discussed above, we recognise concerns around the potential conflict of interest between consortia and providers. Some of our members have suggested that consortia will need to appoint external representatives to assist in the scrutiny of their primary care commissioning. A committee elected by GPs in the consortium may be able to hold the authority.

18.  Dentists and optometrists will be providers as well as commissioners, and we can foresee a synergy of interests in developing services in the community wherever possible. There are already cases of local opticians collaborating with Practice Based Commissioning groups, and we expect this approach to develop.

The commissioning of services that either work across [health and social care] boundaries, or are intimately linked is therefore an issue to which the Committee attaches great importance, and we intend to review the effectiveness of the structures proposed in the Bill which are designed to safeguard co-operative arrangements which already exist and promote the development of new ones. (Paragraph 107)

19.  The commissioning of services that work across boundaries or are linked is welcomed. There is huge potential to meet people's needs more effectively and promote the best use of public resources through close working relationships between local authorities and the NHS, to further integrate health with social care, and wider services. Crucial to the maintenance and success of these relationships will be the assembly, analysis and sharing of examples of best practice. This should be informed by patient experience

20.  A vital part of this will be the availability of public health information - this can be a powerful driver to commissioning, but only if there is accurate collation and analysis of patient data, and effective communication and data sharing between commissioners and local authorities.

21.  As outlined in our response to "Liberating the NHS: An Information Revolution"[68], General Practice leads the way in collecting comprehensive data. When secondary care and other organisations record data as effectively, and standards for interoperability are established and implemented, the potential is there for information to be a vital tool in assisting commissioning for service development.

22.  The use of information across organisational boundaries, and hopefully the coordination of care which will follow, will be of use to most service users, but particularly for those with long term conditions, who may currently experience distress and frustration at the lack of "joined-up thinking". The co-ordination of care across different organisations is particularly important in chronic co-morbid conditions.

We intend to review the arrangements proposed in the Bill to enable commissioning consortia to address these issues [cross-area collaboration by consortia in reconfiguring services] effectively; this will include a review of the ability of the new system to encourage commissioning consortia to cooperate in achieving the benefits to patients which may be available from major service reconfiguration. (Paragraph 110)

23.  While consortia are likely to carry out a number of commissioning activities themselves, in some cases, they may choose to act jointly, for instance by adopting a lead commissioner model to negotiate and monitor contracts with shared providers such as large hospital trusts or urgent care providers. As well as joint working between consortia to commission certain services, consortia may also choose to buy in support from external organisations, including Local Authorities and private and voluntary sector bodies.

24.  However, the RCGP has serious concerns that GP commissioning will create a postcode lottery and greater health inequalities. Some consortia will provide certain services that others will not, or cannot afford. The poorer, less mobile patients, and those with multiple chronic medical problems such as the elderly and frail, as well as those in remote and rural areas where choice will continue to be relatively limited, can be expected to lose services. The RCGP would wish to see emerging consortia having official encouragement to work collaboratively with their specialist colleagues and tariffs for integrated care being designed and supported by appropriate contracts.

The Committee intends to review the arrangements proposed in the Bill for enabling consortia to reconcile this potential conflict [between patient choice and commissioning] by enhancing patient choice at the same time as delivering the consortium's clinical and financial priorities. (Paragraph 115)

25.  We know that many patients value being given access to information and choices about their healthcare, and that a culture of shared decision-making (SDM) can be empowering for patients. There is evidence that appropriate SDM can improve adherence, lifestyle change and service usage, and the RCGP has championed this approach for some time.

26.  However, there seems to be a major contradiction between the proposed right of patients to choose from "any willing provider" and the expectation on commissioning consortia to put energy into developing excellent local services which integrate care pathways: integrated care models from the USA align rather than divide providers. The current emphasis on learning from pathfinder consortia will not be operating in a fully developed marketplace, as the envisaged range of providers and the consequences of their competition have not yet emerged.

27.  Our members have highlighted the clear ethical conflict between the need for managing population health needs on a limited budget, and meeting individual patient expectations as they present to their GP. As commissioners, GPs will need to balance doing what is best for their patients and what makes budgetary sense for the wider population within their consortium of practices. This risks misunderstanding and loss of trust by patients who see GP decisions as financially rather than evidence based. Patients may play the system and "shop around" (which they will be encouraged to do by the proposed abolition of practice boundaries) until they find a more pliant GP. This will result in duplication of consultation costs at the very least and slowly see a drift to market fragmentation. This is reason enough for piloting the reforms so that these fears can be substantiated or confounded and addressed accordingly, and we would also advocate a site of primary registration within a geographical boundary near a patient's home.

28.  The policy of "any willing provider" model appears contradictory to the rationale for commissioning for whole populations and communities. Some members noted a contradiction between the emphasis on unlimited individual choice and the policies on localism, when set against the constraints being put on commissioners. More than 70% of GPs who responded to our recent survey said they disagreed or strongly-disagreed that the concept of "any willing provider" would either achieve a patient-led NHS, or improve healthcare outcomes. We would prefer "enough excellent providers" to "any willing", and to be able to make the decisions about what is needed for our local communities.

29.  A further significant concern is the effective abolition of practice boundaries implied within the White Paper by the assertion that patients will be able to choose any GP that they wish to see. As previously argued by the College[69], this will have a significant impact on GP workload and continuity of care, exacerbate existing inequalities between practices, and potentially place a terminal strain on some, particularly rural, local services. The geographically defined GP practice area is relevant in relation to working with other specialised health services (such as for mental health, midwifery/health visitor/district nurse) and local authorities (social care and public health) so abolition will undermine interaction with these other services.

The Committee does not find the current stance on patient and public engagement in commissioning persuasive. The National Health Service uses taxpayers' resources to deliver a service in which a high proportion of citizens take a close interest both as taxpayers and actual or potential patients. While the Department may be right to point out that there is no special virtue in uniformity of structure, the Committee regards the principle that there should be greater accountability by commissioners for their commissioning decisions as important. We therefore intend to review the arrangements for local accountability proposed in the Bill. (Paragraph 118)

30.  We accept the principle that patients and the public are involved from the outset in every aspect of evaluating needs, planning services and delivering care. Through sharing information, decisions, power and responsibility with our communities, we believe patients will see real improvements.

31.  As discussed above, there is huge potential to meet people's needs more effectively and promote the best use of public resources through close working relationships between local authorities and the NHS, to further integrate health with social care, and wider services.

32.  The proposals for local HealthWatch to engage with local authorities and GP consortia, provided they are established sensibly and with a view to being fully representative, are a useful start as a way to get patients involved in commissioning decisions.

33.  We also support the inclusion of lay members on consortia boards, and association with patient groups at practice and consortium level, though the viability of these will depend on the management allowance apportioned to consortia. If consortia and the NHSCB publish full financial and other information, such as their vision, aims and principles, and the public are educated in the opportunities and limits of commissioning, there will be a real opportunity for local public scrutiny and engagement with decisions made.

The Government must support consortia and existing commissioning organisations to form clear and credible plans for debt eradication and for tackling structural deficits within their local health economy. The Committee intends to further review this issue in its further work. (Paragraph 123)

34.  We are aware that GPs have been asked to take on an enormous new set of responsibilities and challenges. In addition to holding concerns about the damaging effect of dismantling much of what is good about the present system, we believe it is vital to ensure GPs are supported in their new role and protected from unfair criticism arising from financial constraints. GPs will need to set aside time from patient care in order to take up new responsibilities in commissioning consortia. The government must ensure that proper resources are provided for the running of consortia.

35.  We welcome that the Health and Social Care Bill proposes a statutory failure regime for commissioners, which will include powers for the NHS Commissioning Board to establish and maintain a risk pool with consortia, to issue guidance to consortia on financial risk management and to intervene where there is a significant risk of financial failure.

36.  Anything that detracts from GPs being able to deliver excellent holistic care to patients is of concern to the RCGP. The Government must therefore ensure mechanisms are in place so that consortia do not start off with inherited debit.


37.  The RCGP supports stronger clinical leadership for commissioning services for patients and for those patients and their communities to enjoy health care which meets the local needs. However, we have concerns about the pace and extent of the reforms against the context of efficiency cuts and the lack of evidence to support many of the reforms and little commitment to pilot or trial the changes.

38.  Effective Consortia will be built on deep engagement with clinicians, patients and the public, in which information is shared openly, values and priorities are developed in collaboration, and services are delivered in a context in which patient empowerment and community organising are key drivers for change.

Professor Amanda Howe MA MD MEd FRCGP
Honorary Secretary of Council

February 2011

67   The Future Direction of General Practice: a roadmap. London: RCGP, 2007.; Primary Care Federations - Putting patients first. London: RCGP, 2008. Back

68   RCGP Response to Liberating the NHS: An Information Revolution. January 2011. Back

69   RCGP response to Department of Health consultation "Your Choice of GP Practice". 2010. Back

previous page contents next page

© Parliamentary copyright 2011
Prepared 5 April 2011